Dr. Julie Ishida is establishing herself as a young investigator in patient-oriented clinical research aimed at improving the quality of medication prescribing for patients with kidney disease. Her work to date includes studies pertaining to medication safety in hemodialysis patients, and this K23 proposal will allow Dr. Ishida to further her research and training with the ultimate goal of establishing herself as a national leader in optimizing the appropriateness of medication prescribing for patients with kidney disease. In this application, Dr. Ishida will focus on informing the decision-making process for prescribing analgesic medications to hemodialysis patients through the following aims: Aim 1: Evaluate the effect of analgesic medications on risk of major adverse outcomes in hemodialysis patients. Aim 2: Define prediction models for determining risk of major adverse outcomes based on individual hemodialysis patient and analgesic medication characteristics. Aim 3: Develop and pilot test a digital tool that providers can use to assess the risks for major adverse outcomes in hemodialysis patients receiving analgesic medications. The collaborative environment at University of California, San Francisco (UCSF) will provide an ideal environment for Dr. Ishida's career development. She has assembled a multi-disciplinary mentorship team led by Dr. Kirsten Johansen, Professor of Nephrology at UCSF and the San Francisco VA (SFVA), and an expert clinical researcher on the optimal care of hemodialysis patients. Her co-mentoring team will include: Dr. Charles McCulloch, Professor and Head of the Division of Biostatistics at UCSF, an expert in longitudinal analysis; Dr. Michael Steinman, Associate Professor of Medicine at UCSF and the SFVA, a national leader in improving the quality of medication prescribing for older adults; Dr. Annette Molinaro, Associate Professor in the Departments of Neurosurgery ad Epidemiology & Biostatistics at UCSF, an expert in risk prediction methods and Dr. Christopher Koenig, Assistant Professor of Medicine at UCSF and the SFVA, an expert in qualitative research methods and implementation science. Dr. John Hixson, Assistant Professor of Neurology at the SFVA and a digital health expert, will provide guidance regarding the development of the digital risk prediction tool. This award will allow Dr. Ishida to obtain career development mentorship and training in the following areas: a) advanced biostatistics and study design, b) risk prediction methods, c) primary data collection and qualitative research methods and d) implementation science. By the end of the K23 award period, Dr. Ishida will apply for R01 funding to conduct a randomized trial of an intervention, which will incorporate the risk predictio tool developed in the K23 project, on the appropriateness of analgesic prescriptions in hemodialysis patients.